Committees

Justice Committee launches new inquiry into the Coroner Service to examine progress

20 November 2023

The Justice Committee has today launched a new inquiry into the Coroner Service to examine changes made since 2021.

In 2022, 208,400 deaths were reported to coroners, the highest since 2019, and up 7% compared to 2021. This represents 39% of all registered deaths, which is again at its highest level since 2019. 43% of these led to post-mortems. In 2022, 35,600 inquest conclusions were recorded in total, up 10% on 2021.

The cross-party committee of MPs conducted an inquiry examining the effectiveness and capacity of the Coroner Service during the 2019-21 session of Parliament looking at whether enough progress had been made on improving bereaved people's experiences of the Coroner Service. Changes designed to improve the service were made by the Coroners and Justice Act 2009 and implemented in 2013.

The new inquiry will build on the Committee’s work in this area and consider what has changed in the Coroner Service since 2021, checking whether progress has been made on the Committee’s earlier recommendations.

The Coroner Service exists to identify the deceased in a local area and ascertain causes of death. Coroners must investigate deaths that have been reported to them if they think that: the death may have been violent or unnatural; the cause of death is unknown or the person died in prison, police custody or another type of state detention.

Coroners are organised and funded by local authorities. There are currently 80 coroner areas in England and Wales, each staffed differently. A Chief Coroner for England and Wales – a role created by the 2009 Act – provides leadership and guidance to Coroners.

Chair's comment

Justic Committee Chair, Sir Bob Neill MP, said: 

“Since the Committee’s earlier inquiry examining the effectiveness and capacity of the Coroner Service, there has been a notable rise in deaths reported to coroners and inquests held.

“It is right the Committee follows up its previous recommendations and checks on the progress made across the Coroner Service since 2021, particularly in light of this increased demand.

“We intend to visit coroners to see how bereaved families’ experiences vary, examining in particular any regional disparities, delays and Coroners’ responsiveness to the particular requirements of faith burials and funerary practices.”

Terms of reference    

The Justice Committee invites written submissions by Monday 15 January 2024 addressing any or all of the following questions: 

  1. What progress has been made towards the goal of placing bereaved families at the heart of the Coroner Service.
  2. What progress has been made by the Government in implementing those of the Committee’s earlier recommendations which it accepted in September 2021.
  3. What progress has been made by the Government in responding to those of the Committee’s recommendations which it was unable to address in September 2021.
  4. Given that the Government has rejected the Committee’s recommendation to unite local coroner services into a single service, what more can be done to reduce regional variation and ensure that a consistent service operates across England and Wales.
  5. Whether more can be done to make best use of the Coroner Service’s role in learning lessons and preventing future deaths. In particular (a) are Coroners across England and Wales making consistent use of their power to issue Prevention of Future Death (PFD) reports? And (b) could the way PFD reports are being used to help prevent future deaths be improved?
  6. How are Coroners responding to the requirements of faith burials and funerary practices, especially in relation to early release of bodies and provision of non-invasive autopsies? Is there a consistent and satisfactory approach across England and Wales?
  7. Whether there is evidence that inquests are taking too long to be completed, and if so why, and what can be done in response.
  8. Whether the Coroners’ Service has recovered from the challenges of the Covid-19 pandemic, and what lessons can be drawn from it.
  9. Whether there are any other changes to the way the Coroner Service operates that could be made to improve its effectiveness.

Further information

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